Is scan-negative cauda equina syndrome a functional neurological disorder?:A pilot study

Background and purpose: Cauda equina syndrome (CES) is a neurosurgical emergency which warrants lumbar magnetic resonance imaging (MRI). Many patients with suggestive symptoms of CES have no radiological correlate. A functional (non‐organic) aetiology has been proposed in some, but currently little is known about this patient group and their clinical outcomes. / Methods: At a tertiary referral centre, 155 adult patients underwent urgent lumbar MRI for suspected CES in 1 year from December 2014. Data regarding clinical symptoms and follow‐up were obtained from records. Patients were divided into CES (n = 25), radiculopathy (n = 68) and scan‐negative (SN) groups (n = 62) from scans. Up to 3 years post‐discharge, postal questionnaires were sent to patients with Oswestry Disability Index, Pain Catastrophizing score, Patient Health Questionnaire (PHQ) 9, Generalized Anxiety Disorder (GAD) 7, PHQ 15 and Work and Social Adjustment Scale measures. / Results: No clinical symptoms were found to differentiate CES from SN patients. Functional comorbidities were significantly more common in SN patients but mental health diagnosis frequency did not differ. Follow‐up was variable with no consistent referral pathways, particularly for the SN group. 33% (n = 47) responded to the postal questionnaires; high levels of pain, symptom chronicity and disability were ubiquitous but self‐reported mental health diagnoses and PHQ 15 were higher for SN patients. / Conclusions: Conflicting data suggest further research is needed to investigate the prevalence of mental illness and somatic symptoms in SN cases. SN patients have higher rates of comorbid functional disorders and inconsistent referral pathways. Self‐report measures indicate impaired quality of life across all groups. The low response rate limits the generalizability of findings but neuropsychiatric assessment and care pathway optimization should be considered

Substance misuse teaching:a patient safety issue

AIMS: Clinical substance misuse presentations are commonly managed by Psychiatry Core Trainees (CTs) out of hours. However, specialist teaching is not included in the Maudsley Training Program (MTP) induction. We aimed to investigate whether this was of clinical concern and, if so identify interventions to address it. BACKGROUND: The association of substance misuse disorder and mental illness is widely recognised. The Adult Psychiatric Morbidity Survey 2014 reported that half of people dependent on drugs other than cannabis were receiving mental health treatment. Substance use substantially impacts clinical risk; 57% of patient suicides in 2017 had a history of substance misuse. It also effects emergency psychiatric services: 55-80% of patients detained under S136 are intoxicated. Therefore, it is imperative for patient safety that CTs can assess and manage these patients appropriately. The Royal College of Psychiatrists recognises the need for specialist substance misuse knowledge and skills, and lists this as a key ‘Intended Learning Outcome’ for CTs. Unfortunately, the availability of specialist drug and alcohol service placements for CTs has significantly declined. Only one placement is available per MTP rotation. Teaching is therefore relied upon to gain these competencies. METHOD: Using a cross-sectional survey we explored CTs confidence in recognising and managing substance misuse presentations, knowledge of where to seek guidance and asked for teaching suggestions. We surveyed two CT1 cohorts in 2017 and 2019. RESULT: Fifty-one CTs took the survey. Of these 92% did not feel prepared to manage acute substance intoxication or withdrawal and 96% would like relevant teaching at the start of CT1. Furthermore, 67% did not know where they could seek guidance. CTs felt confident at recognising and managing alcohol related presentations. However, they were less confident in recognising opioid withdrawal, how to safely prescribe opioid substitution therapy (OST), and the usual doses of OST (65%, 94%, 94% rated ‘neither confident nor not confident’ or below, respectively). CTs were not confident at recognising GBL and cannabinoid withdrawal, principles of harm minimisation, assessing readiness to change, delivering Brief Interventions and teaching patients to use Naloxone. CONCLUSION: The results were exceptionally similar between cohorts, demonstrating reliability of our findings and that CTs lack of substance misuse knowledge is a significant clinical concern. To address this deficit of knowledge, we are writing an introductory lecture with supporting guidance in the induction pack, developing an online video resource, and moving key substance misuse lectures to earlier in the MTP taught programme